Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> _ <br /> 5" -e. ENVIRONMENTAL HEALTH PERMIT PUMP&WELI. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> matte in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address , 1 Ii City/Town C� <br /> Owner's Name A I-e-W Phone <br /> Address 16(2C ���'tt9 i�y`f� City <br /> Contractor's Name at License# Business Phone6f <br /> r Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran a on File With SJLHD? Yes_ L� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTgi--' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 11119 171f _ Cesspool/Seepage Pit Other <br /> Property Line 1% Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9-60MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> y ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A/ �� �R S'v1 CJw J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: W'State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _Approximate Depth <br /> Describe Material and Procedure -=-=°- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> ` permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: Date: -7 111 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT iUSE ONLY <br /> PHASE I 1 Date����~�� <br /> i Application Accepted By <br /> G Additional Comments: <br /> r Phase II Grout Inspection se 111 final Inspection <br /> Inspection By Date Inspection-By Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> + <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DQE CHECKED <br /> B <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER . <br /> OTHER ^' - <br /> ►.. Received by Date Receipt No. Permit No. is a ce atcrl Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1807 E. A2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />